maureen underwood, l.c.s.w. - hazeldenjudith springer, psy.d. ... chapter 7 engaging parents 107...

Maureen Underwood, L.C.S.W.Judith Springer, Psy.D.

Michelle Ann-Rish Scott, M.S.W., Ph.D.Society for the Prevention of Teen Suicide

®

Lifelines Intervention

Helping Students At Risk for Suicide

HazeldenCenter City, Minnesota 55012hazelden.org

© 2011 by Hazelden FoundationAll rights reserved. Published 2011Printed in the United States of America

Unless a statement on the page grants permission to duplicate or permission has been obtained from the publisher, no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, scanning, or otherwise—without the express written permission of the publisher. Failure to comply with these terms may expose you to legal action and damages for copyright infringement.

ISBN: 978-1-61649-157-4

Notice and DisclaimerThis curriculum is for educational and informational purposes only and should not be considered, or used as a substitute for, professional medical/psychological advice, diagnosis, and treatment. Hazelden makes no warranty, guarantee, or promise, express or implied, regarding the effective-ness of this curriculum in the prevention of suicide in specific situations. Hazelden does not take responsibility for any loss, injury, or damage caused by using the curriculum information, and in no event shall Hazelden, its employees, or its contractors or agents be liable for any special indirect or consequential damages or any loss or damages whatsoever resulting from injury, loss of income or profits, whether in an action of contract, negligence, or other tortious action, arising in connection with the use or performance of any information contained in the curriculum or associated materials. Hazelden does not monitor and is not responsible for statements made by instructors or others, or for the quality of instruction provided in conjunction with this curriculum.

The lyrics from “Whore to a Chainsaw” by Thy Art Is Murder on page 109 are used with permission.

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Cover design by David SpohnInterior design and typesetting by Madeline Berglund

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Duplicating this page is illegal. Do not copy this material without written permission from the publisher.

Contents

Acknowledgments vii How to Use the CD-ROM ix

Introduction We’reAllinThisTogether 1

Chapter 1 BuildingonaStrongFoundation:Administrative FrameofReference 7 Chapter 2 HowInterventionBegins:TheIntersectionofValues, Knowledge,andEmpathy 15

Chapter 3 InTheirOwnWords:ListentoYouthSpeak 31

Chapter 4 Identification:WhoAretheStudentsWhoMightBeAtRisk? 45

Chapter 5 SettingtheStage:PreparingfortheAssessmentInterview 61

Chapter 6 “TellMeMore”:TheAssessmentInterview 87

Chapter 7 EngagingParents 107

Chapter 8 PuttingItTogether:MakingEffectiveReferrals 131

Chapter 9 SpecialChallengesinIntervention 147

Students Returning to School after a Suicide Attempt 149 Gifted Students 153 Students Who Are Bullied 158 Sexual Minority Students 167 Special Education Students 173

Chapter 10 EnhancingProtectiveFactorsandBuildingResilience 179

References 191 About the Authors 197

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Acknowledgments

The competent-community focus of the Lifelines model parallels the wide range of acknowledgments we would like to make for help in putting this manual together.

At the individual level, our support ranged from experienced professionals like Teresa Mosley and Susan Paynter, who shared their expertise on counseling gifted students, to Aubrey Clark, social work intern at Monmouth University who helped us identify important resources that enriched the manual’s content.

We are grateful as well to Pamela Foster, our editor at Hazelden Publishing, for continuing to patiently guide the Lifelines projects through what seem to us the intricacies of the publishing maze.

Sharon Shepherd-Levine and Bob Griffiths added their insightful creative stamp to the video elements, and we always appreciate the sensitive and thoughtful way they translate what’s on the written page to the screen.

Scott Fritz of the Society for the Prevention of Teen Suicide continues, as always, to inspire us with his passionate commitment to the development of accu-rate and quality training and public awareness materials. We remain humbled by his dedication to the cause.

To our families, who understand the somewhat consuming nature of this project, your support is a footnote on every page.

And finally, the model we describe in the following pages would have remained simply an idea in our minds without the schools that invited us in to meet and train their resource staff and that gave us invaluable feedback that helped us create a model we feel is relevant to the mandate and the mission of schools. We especially appreciate the wonderful advisors and students in the peer program in West New York, New Jersey, who provide a shining example of how students can be an invalu-able resource for positive change in schools.


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How to Use the CD-ROM

Included with this manual is a CD-ROM that contains a variety of reproducible resources for school resource staff to help implement Lifelines Intervention. All the documents on the CD-ROM can be printed and copied for personal use without worry of copyright infringement.

Whenever you see this icon in the margin of the manual’s pages, it means the indicated resource is located on the CD-ROM. To open the documents on the CD-ROM, you will need Adobe Reader. If you don’t have Adobe Reader, you can download the software for free at www.adobe.com.

For a list of what is contained on the CD-ROM and for further instructions, please see the Read Me First document on the CD-ROM.


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We’re All in This Together

Introduction

“I was in my second year as a school counselor when I got my first referral for assessment of a student that a teacher thought might be suicidal. I remembered what I had learned in graduate school about depression in adolescence, but I didn’t remember any specifics about suicide risk assessment. I knew some questions to ask, but I’m sure there were others I missed. I don’t know who was more anxious about the interview—the student or me!”

—MIssIssIppI school counselor

Why DiD We Write this Manual?

There’s been a trend in recent years to provide more education in schools about mental health, especially as it relates to suicide prevention. Many health curricula teach students about signs and symptoms of depression and other mental disorders. Faculty and staff may get the same type of training at presentations or in-service workshops. The Lifelines approach uses a different tactic. While we recognize the importance of mental health education, our slant on youth suicide prevention is broader and focuses on mental wellness rather than on mental illness.

The signature of Lifelines has been the establishment of a “competent school community,” in which all members can identify the signs of suicide risk and know what to do in response. This book is written for school resource staff who are often called upon to intervene when there is concern about a student’s potential suicide

Lifelines Intervention• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

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risk. Although we recognize that assessment by a community mental health profes-sional is ultimately required with at-risk students, we also know that school staff may find themselves in a position of having to provide targeted interventions to facilitate those subsequent referrals. This manual reflects your unique role in this intervention process. Our goal is to provide you with helpful tips and resources to improve your comfort level in asking the questions that you need to ask in order to help save a life.

Lifelines also highlights the promotion of resilience or “protective” factors for youth—including assisting students in identifying trusted adults in their support network and teaching them that it’s okay to ask for help.

There is, however, a paradox in school-based suicide prevention: when it’s effective, more students are identified as being at potential risk. When the compe-tent suicide prevention community is in action, this identification can come from a variety of sources: peers, faculty and staff, parents, or the at-risk students them-selves. Whatever the source, however, a chain of events should be set in motion to create a safety net for the student. This safety net includes not just the resources of the school but also those of the community at large.

What is InterventIon?

We believe that school-based intervention for suicide risk is three-tiered: one tier addresses early identification and assessment of at-risk students, the second makes referral to community resources for additional services, and the final tier enhances the protective factors that increase resilience and provide buffers from stress.

What is the school’s role in intervention?

The safety net for at-risk students created in the school does include assessment and intervention grounded in sound mental health theory: identify the problem, gather relevant information, and make a referral (Granello and Granello 2007).

the school’s role in intervention

• Identification and Assessment

• Referral

• Enhancement of Protective Factors


Introduction We’re All in This Together• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

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And while this initial intervention is critical, its scope is limited. Lifelines firmly believes that schools are not mental health centers; they simply take the first step in getting students the mental health care they need from community resources. The guidelines that Lifelines presents for school-based interventions reflect that bias.

Referral to community-based resources for assessment and/or treatment is the second tier of intervention. Effective referrals involve both the student and the student’s parents and require knowledge about community resources so that the resource is matched to the student’s needs.

In regard to the final aspect of intervention in the school—the creation and support of “protective factors” for students—if a school is a competent and com-passionate community for its students, protective factors will be inherent in the school’s culture. These factors will include teaching students that it’s okay to ask for help, engaging them in school and community activities, recognizing student accomplishments, and encouraging prosocial behavior by all school community members, including faculty and staff.

There’s another reason schools should consider intervention as a part of a comprehensive suicide prevention protocol. Research has demonstrated that when schools implement student awareness curricula for suicide prevention, self- and peer-generated referrals tend to increase. However, while school resource staff can perform the “gatekeeper” function of making initial assessments and subsequent referrals to local mental health resources for further evaluation and follow-up, they are generally without specific protocols to guide them in these critical tasks. There are, for example, no clinical tools on the National Registry of Evidence-based Programs and Practices (NREPP) or the Best Practices Registry (BPR) of the Suicide Prevention Resource Center (SPRC) detail procedures to be used in schools. A standardized clinical framework that asks explicit questions about suicide risk is, of course, indicated, but what are the parameters for questioning in a school setting? What format should schools use to communicate information obtained in the school setting to local mental health treatment resources? And how can parents or guardians who may misunderstand or distrust mental health services be engaged as collaborators in the process?

The interventions in this manual build on the foundation of the competent and compassionate school community described in the Lifelines prevention model, as listed on NREPP. The manual adapts the training format for the assessment and management of suicide risk created by the Suicide Prevention Resource Center to the resources and limitations of school settings. The manual begins with a dis-cussion of the historical context of suicide and an exploration of personal values and attitudes toward suicide. It then takes school resource staff through a pro-cess that includes preparing for the interview with the potentially at-risk student,


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gathering collateral information, and addressing specific topics in an interview format called “Tell Me More.” The manual reviews techniques that can be useful with students who are challenging to interview, and it provides clear guidance in involving parents and guardians as partners in suicide prevention. It addresses specific needs presented by students who are bullied, members of sexual minorities, gifted, or in special education classes. Finally, this manual describes ways in which schools can increase protective factors that promote resiliency.

What are the objectives of this Manual?

As you read this manual, you’ll see it begins by creating a foundation of knowl-edge that grounds the school’s role in assessment and intervention. It continues by addressing the following objectives:

1. To provide a context for contemporary societal values and attitudes about suicide by reviewing suicide from an historical perspective

2.To highlight the role of personal values and experiences in the assessment/intervention process

3.To present epidemiological information about suicide risk to facilitate early identification of at-risk students

4.To review a protocol for an assessment interview

5.To outline strategies for engaging students and parents in the assessment/referral process

6.To call attention to special categories of students who may be at elevated suicide risk

hoW is this Manual organizeD?

This manual reflects what we have learned about the role of school-based resources from our sixty-plus years of collective experience in school settings. The chapters are structured around typical questions educators and school resource staff ask about intervention with potentially suicidal students. In addition to reviewing basic information about suicide to create a solid foundation for an intervention, the manual provides a template for the initial assessment in the school setting. We review the reasoning behind including particular questions in the assessment interview. The challenge of involving the student’s parents in the referral process is discussed in detail, and the CD-ROM contains strategies for engaging parents. Sample interviews with both students and parents are included on the DVD.


Introduction We’re All in This Together• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

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While all interventions in this book are grounded in sound theory, their rel-evance to the school is explained and practical guidelines for implementation are suggested. This reflects another thread that runs through the entire Lifelines series: the usefulness of theory is in its application to real-life issues and problems. John Kalafat, coauthor of Lifelines: A Suicide Prevention Program, put it this way: “I may be a researcher and educator, but I’m also a pragmatist from the ‘so what?’ school of training. If there’s not a practical reason to learn something, what’s the point of teaching it?” John believed that adult learning theory was correct in its assess-ment that the information people learn best is relevant to their immediate work and should help them reach personal and professional goals—the “what’s in it for them” application of theory to practice. Thus, each chapter contains quotations that bring life to the content and reflect its applicability to the experiences of different members of the competent school community.

Each chapter includes a list of resources related to specific content. As you will see, these are by no means exhaustive; they are resources that we have found par-ticularly helpful. They are not meant to discourage readers from seeking additional resource material of their own. Whenever possible, Internet addresses are given to facilitate ease of access.

Each chapter in the Lifelines Postvention manual ended with a section called “In a Perfect World . . .” The section encouraged readers to think about the ways in which they could apply the manual’s content in their schools. Each chapter in this manual concludes with a short section entitled “In Your Experience . . .” It asks readers to consider the more personal ways in which chapter content can inform their interventions.

What is the bottoM line?

This manual mirrors the Lifelines philosophy that theory is only as useful as its application. Sections of the manual can be used as immediate resources for the assessment and referral of a potentially suicidal student. The CD-ROM contains a PDF slide show that districts can use to train all resource staff in a consistent approach to assessment and referral. The notes that accompany each slide include specific references to chapter content to help you organize a training presentation that reflects fidelity to the Lifelines model.


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7

Building on a Strong Foundation: Administrative

Frame of Reference

Chapter 1

“As the school administrator of a large, metropolitan district, I am acutely concerned about doing everything I can to educate the students in my charge in a safe, nonviolent environment. In recent years, I’ve felt that my ability to respond to the needs of students at risk for suicide has been compromised by students’ rights activists championing the cause of student privacy. Between hIpAA and FerpA and threats of lawsuits, I feel between a rock and a hard place when I just want to do what’s right for my kids.”

—school superIntendent

Schools today often find themselves in paradoxical positions. On the one hand, they seem to be held increasingly accountable for responding to the needs of students who might be at risk for suicide; on the other hand, they can be bombarded with caveats about respecting the privacy of individual students and families. Where is the balancing point? Certainly school board legal counsel can provide interpreta-tion on a case-by-case basis, but a review of the big picture might provide some clarity for administrators and staff on the most commonly misunderstood parts of the process (Borowsky, Ireland, and Resnick 2001).

However, the role of school administration in suicide prevention and interven-tion is much broader than simply interpreting policies and establishing response protocols. The administration creates the foundation on which the competent


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school community is based. The administration’s commitment to the well-being of all members of the school community is bred into the culture of the school. In fact, when this doesn’t occur, its absence is noted and resented by faculty and staff.

This chapter will discuss ways in which that administrative commitment should be demonstrated. We will review the components of the competent school community and focus specifically on the administrative issues that should be included in a comprehensive intervention plan.

By the end of this chapter, you will be able to

• understand the structure of a comprehensive youth suicide prevention program in a competent school community

• recognize when there is a need for formalized agreements with off-campus resources

• understand the applications of HIPAA and FERPA to the school in general and to students at risk for suicide

What are the coMponents of a coMpetent youth suiciDe prevention coMMunity?

Perhaps the easiest way to envision this community is through the following diagram:

Administrative Foundation

Prevention

Intervention

Postvention


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Let’s start at the bottom and work our way to the top. The administrative foundation for the competent school community is based on the support and commitment of the school board, articulated through the principal, to policies and procedures that address the range of needs presented by students who might be at risk for suicide. In most schools, these policies address protocols for dealing with students suspected of being at suicide risk and students who make attempts on or off school property, as well as strategies for assisting the school community in the event of a death by suicide.

Where does your school stand in the comprehensiveness of your policy devel-opment? The CD-ROM provides a readiness survey that makes it easy to assess how your school currently measures up and where you might need to fill in the blanks. Also provided is a sample policy that covers the essential components around which comprehensive protocols can be structured.

The second level of the competent school community is prevention. The essen-tials of prevention, addressed in Lifelines: A Suicide Prevention Program, include several components. Prevention begins with providing youth suicide awareness training for all faculty and school staff. The comprehensiveness of this approach ensures that everyone who comes in contact with students—from classroom fac-ulty to bus drivers to cafeteria staff—understands the importance of their limited but critical role: to identify students who might be at risk for suicide and refer them to the appropriate school resources for assessment. Parents are also recog-nized as a key piece of the prevention equation, with specific materials designed to increase their awareness about the realities of youth suicide and to prepare them to be advocates for their children in the event they need professional mental health assistance. Finally, students are integrated into prevention by helping them to recognize signs of potential risk in themselves and others and to identify trusted adults to whom they can turn for assistance.

Intervention, which is the subject of this manual, recognizes that after poten-tially at-risk youth are identified, the next step involves referral to school resource staff for initial assessment. Again, in the context of the limited responsibility of the school, the format of this assessment, which is based on clinical interviewing principles, is clearly structured to focus on information that clarifies the school’s reasons for concern about the student. It outlines what additional information should be gathered to facilitate a referral to community resources and reviews the necessary documentation to protect the school from liability issues.

The final part of the model, responding in the aftermath of a death within the school community, is covered in Lifelines Postvention: Responding to Suicide and Other Traumatic Death. Although Postvention may be the least frequently used

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Lifelines component, it is nonetheless an intrinsic part of a proactive, competent school community that takes its commitment to the safety of its students seriously.

as an aDMinistrator, What are the Key aspects of intervention to Which i neeD to pay attention?

Although many schools handle referral arrangements with local mental health providers in informal ways, there has been increasing recognition of the value of drafting more formalized memorandums that clarify what a school can expect from these community resources. The agreements usually reference the ways in which the agency or provider will respond to requests from the school for risk assessments, clarify the information that will be shared with the school to facilitate the provision of school-based support to an at-risk student who is in treatment, and address how the agency or provider will assist the school in dealing with crises. These types of agreements can be especially helpful when the school is requesting an emergency assessment for imminent suicide risk. This kind of evaluation gen-erally takes place in a crisis center or emergency room. Having established and formalized relationships with these types of referral sources in advance of a crisis can be very helpful in streamlining the process at a point when time may be critical.

These formalized memorandums are not necessary with every provider to whom the school makes referrals. For example, most private mental health practitioners will have their own “release of information” documents which specify the infor-mation they’ve received permission from the parents or guardians to share with the school. When referrals are made to mental health providers, it may be helpful to specifically inform parents that these forms are available and must be signed by them to allow the therapist to communicate limited but essential information to the school so the school can help support their child’s mental health needs. Another aspect of record keeping that should concern a school administrator is the form that documents staff contact with a student’s parents and subsequent referral recommendations. It can be very important to document that a school has been diligent in turning over its responsibility for the safety of an at-risk student to his or her parents and in requiring follow-up with an off-campus mental health professional. A sample form for documentation of parental/guardian follow-up is located on the CD-ROM.

An administrative issue that frequently challenges school officials when mak-ing emergency referrals to crisis services is asking for written documentation that the student is no longer at risk for suicide as a condition of the student’s return to school. Although mental health resources are usually able to determine a student’s current level of suicide risk and recommend appropriate treatment protocols, they are not able to predict definitively when the risk for suicide has abated.

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The unfortunate reality, confirmed by the Youth Risk Behavior Survey con-ducted annually in schools across the country, is that as many as 13 percent of high school students have considered suicide as an option in the preceding academic year. There will always be students who are at risk for suicide in our schools. That’s why it’s so important to have a trained faculty and staff who can recognize signs of escalating risk and make referrals for additional assessment. That’s also why it’s critical to have collaborative relationships with local mental health resources that can provide guidance about the ways in which the school community can support potentially suicidal students.

What about those confiDentiality constraints in hipaa anD ferpa?

First let’s talk about HIPAA, which stands for the Health Insurance Portability and Accountability Act, a 1996 federal statute. Although the act actually covers many topics unrelated to privacy, the privacy aspect is what we’ll look at in relationship to schools. Covered entities under HIPAA are

• health care clearinghouses

• health plans

• health care providers

A simple rule of thumb is that any provider who bills an insurance company or health plan is a covered entity under HIPAA. Some school districts fit the defini-tion of a “covered entity” under HIPAA because they conduct electronic transac-tions for payment as Medicaid providers in the School Health and Related Services (SHARS) program. Most school districts, however, do not fit the definition of a

“covered entity.” To make sure, districts should consult with their legal advisors to determine whether HIPAA applies to them.

Even if a school is covered by HIPAA, however, the HIPAA Privacy Rule authorizes a health care provider to disclose an individual’s danger to self or others, without the individual’s consent, to another health care provider for that provider’s treatment of the individual. What does this mean in a school when there is a student who may be at risk for suicide? Translated into plain English, this means one counselor can share information about a student’s suicide risk with another member of the school’s resource staff. This can be important to communicate with your resource staff who may misinterpret either HIPAA or the confidentiality pro-tections of their professions to mean that they cannot share what they have been told in the privacy of a counseling session. When there is a question about a per-son’s danger to self or others, confidentiality provisions do not apply.


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Does this mean a school resource person can tell a teacher about a student’s risk for suicide? Yes. Appropriate information needs to be disclosed; however, teachers do not need to know specific diagnoses. Teachers can be told what types of symp-toms to look for and what should be done in the event that those symptoms appear. This does not mean that the entire staff need to know about a student’s mental health problems. Only the minimum necessary information should be disclosed, and only to those with a justifiable need to know.

Now let’s look at FERPA, the Family Educational Rights and Privacy Act of 1974. FERPA had two original goals:

1. To give parents access to the educational records of their children

2.To limit the transferability of records without consent

Despite ambiguities in the original law, it is very clear that nonconsensual disclosures of educational record information in response to an emergency are exempt from the consent requirement (James 1997). It’s also important to note that FERPA does not apply to shared verbal communication. The need for educa-tors to share and receive information about students potentially at risk for suicide is hard to overstate. As Bernard James, J.D., of the National School Safety Center, eloquently puts it: “Educators’ decisions about the needs of a student are based on the quality of the information available to them” (James 1997, 461).

What is the bottoM line?

When a student is potentially at risk for suicide, there is no confidentiality. The importance of saving a life overrides any expectation of privacy.

let’s revieW

As an administrator, you must advocate for the policies and procedures that will help your school provide students with a safe learning environment. Making sure your board has approved policies to address the needs of students at risk for suicide is the essential foundation on which all suicide prevention activities must be based. With policies in place, you can begin to establish written protocols that codify the ways in which your school will address the needs of this vulnerable segment of your school’s population. A key aspect will be making sure that your resource staff members are prepared to intervene when an at-risk student is identified. The following chapters will walk the reader through the steps of this process. They will highlight key aspects and provide suggestions for the practical application of theory to the realities of today’s students and their families.



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resources

Bergren, M. D. “HIPAA Hoopla: Privacy and Security of Identifiable Health Information,” Journal of School Nursing 17, no. 6 (2001): 336–40.

Health, Mental Health, and Safety Guidelines for Schools: Protection of Student and Staff Confidentiality. See www.nationalguidelines.org/guideline .cfm?guideNum=0-03.

“HIPPA” and “FERPA” Questions & Answers for Schools & Day Cares. See www.dphhs.mt.gov/PHSD/Immunization/documents/HIPPA.doc.

National Association of School Nurses. HIPAA and FERPA information. See www.nasn.org.

National School Boards Association. See www.nsba.org.

National Task Force on Confidential Student Health Information. Guidelines for Protecting Confidential Student Health Information. Kent, OH: American School Health Association, 2000.

Youth Risk Behavior Survey. See www.cdc.gov/violenceprevention/pub/youth _suicide.html.

In Your

experience . . . • When was the last time you reviewed your school’s policies for

at-risk students? Is there anything that needs to be updated?

• Are teachers, staff, and administration aware of the exceptions to FERPA when suicide risk is a possibility?

• Have you had experiences with referring students for outside assessment that worked well? Didn’t work at all? What can you learn from these experiences to help you modify your procedures and protocols?


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hanDouts

1-1: Readiness Survey1-2: Suicide Prevention, Intervention, and Postvention Policy and Procedure

Guidelines1-3: Documentation of Parental/Guardian Follow-Up

maureen underwood, l.c.s.w. - hazeldenjudith springer, psy.d. ... chapter 7 engaging parents 107...

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